ICSI or Vasectomy Reversal: What Should You Recommend To Infertile Couples?Anthony J. Thomas Jr., M.D.

A new, sophisticated procedure known as intracytoplasmic sperm injection (ICSI), combined with in vitro fertilization, is offering hope to some previously infertile couples. However, patients have generally higher pregnancy rates with vasectomy reversal than with the newer technology.

ICSI is a highly specialized technology in which a single sperm is injected into a mature oocyte with the potential for fertilization, embryo placement in the female, normal fetal development and birth.

This technique appears to be useful in cases in which the male's normal sperm may be insufficient to allow pregnancy to occur through intercourse, intrauterine insemination, or even standard in vitro fertilization. Pregnancy rates are also enhanced when sperm is aspirated from the epididymis in cases where there is congenital ahsence of the vas deferens or irreparable obstruction of the efferent ductal system.

Favorable Results Achieved

While advanced technology offers an alternative to some couples, our statistics suggests that vasectomy reversal, whether standard vasovasotomy or vasoepididymostomy, results in pregnancy rates which are generally higher than that associated with the newer technology.

In a study published in the Journal of Urology1 on the obstructive interval to pregnancy, we found that in men who had vasectomies for less than three years, 76 percent achieved pregnancy after vasectomy reversal. Those who had vasectomies for three to eight years had a 53 percent success rate; those who had vasectomies for nine to 14 years had a 44 precent pregnancy rate; and those who had vasectomies for 14 years were able to achieve pregnancy in 30 percent of cases following surgery.

Surgery is usually performed under local anesthesia in an outpatient setting. With the aid of the operating microscope, using 9-0 and 10-0 nylon sutures, microsurgical anastomosis of the severed ends of the vas deferens usually takes less than three hours.

Most men can return to work a few days later unless their job requires very strenuous effort. We recommend that strenuous activity be avoided for a couple of weeks following the procedure.

Educating Couples

Couples often ask whether ICSI is preferable to vasectomy reversal because it allows for easier fertilization with a higher success rate. Many are under the false impression that sperm can be obtained easily with a single-needle puncture through rhe scrotal skin or that only one egg is needed.

They are often unaware that when obstructive azoospermia exists, very precise epididymal explorarion and microsurgical aspiration of sperm from the epididymis is required. This risks permanent scarring to the epididymal tubule, making the chances of reversal at a later date much less successful because surgery would require anastomosis of the vas deferens at a level higher than the previous aspiration site.